The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST ALEXIUS HOSPITAL 3933 S BROADWAY SAINT LOUIS, MO 63118 July 1, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and record review, the facility failed to provide within the capability and capacity of the facility's ED a medical screening exam (MSE) sufficient to determine if the presence of an emergency medical condition (EMC) existed for one patient (#6) out of 22 sampled ED records reviewed that presented to the facility's ED from January 1, 2019 through June 20, 2019.
This failed practice by the facility had the potential to delay care and treatment for patients that presented to the ED seeking a medical exam. The facility saw an average of 1,104 patient cases per month and transferred an average of 12 patients per month over the past six months.

Findings included

1. Review of the facility's document titled, "Medical Staff Rules and Regulations," dated 08/2018, showed that "Emergency Services and Care" means an appropriate medical screening examination and evaluation within the capability of the facility, including ancillary services (laboratory, radiology) routinely available to the emergency department, by qualified medical personnel deemed to include emergency physicians and/or attending physicians and/or registered nurses (RN) employed by the hospital to determine whether an "emergency medical condition exists".

Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - ED to ED Transfers," dated 08/2018, showed the following directives for staff:
- The facility is to ensure the safe examination, treatment, stabilization and transfer of those patients who may require hospitalization and for varying reasons cannot be hospitalized at our facility.
- Provide an appropriate MSE to any individual who comes to the emergency department. The purpose of the MSE is to determine whether or not an emergency medical condition (EMC) exists.
- Emergency Medical Condition - is a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that absence of immediate medical attention could be reasonable expected to result in: Placing the health of the individual in serious jeopardy or serious impairment to any bodily function.

Review of the facility's policy titled, "Laboratory Turn Around Times," dated 05/2016, showed that:
- All STATS (without delay, immediately)/Critical (uncertain prognosis and death may be imminent) tests for basic chemistry (BMP, a test that measures chemicals in the blood and shows how well certain organs are functioning), hematology (blood and blood forming organs), coagulation (process when blood forms a clot), and urinalysis (UA, a test of urine to determine if an infection is present) testing should be reported within 25 minutes from the time received in the laboratory.
- All STATS/Critical test for CK-MB (a cardiac marker used to diagnose acute myocardial infarction, MI - heart attack), Troponin (a blood test used to help detect injury to heart muscles), TSH (Thyroid Stimulating Hormone, produces hormones that regulate the body's metabolic rate, heart/digestive function, muscle control, brain development, mood and bone maintenance), and Abuse Drug Screening (UDS, a test used to detect either illegal or prescribed substances in either blood or urine) should be reported within 50 minutes from the time received in the laboratory.
- Most routine test are reported within four hours from the time received in the laboratory.
- Nursing divisions will be notified of unusual delays.

2. Review of Patient #6's ED record showed:
- The patient presented to the facility's ED on 06/17/19 at 2:21 PM per private vehicle with complaints of pain in her right calf for approximately 10 days and shortness of breath for five days or more.
- The ED record showed that the patient had a history of hypertension (high blood pressure), diabetes (abnormal levels of sugar in the blood) and asthma (a respiratory condition marked by spasms in the tubes of the lungs, causing difficulty in breathing).
- Staff S, ED Physician, wrote an order for laboratory test to be performed on the patient for D-Dimer (test used to detect blood clots in the body) and B-type natriuretic peptide (BNP, test that detect heart failure).
- The laboratory test results were not received prior to the patient's discharge because the test had to be sent out of the facility because the laboratory department did not have the supplies available as a result of inability to pay the vendor.
- The patient's primary care physician was not notified of the results for the D-Dimer and BNP that was collected on 06/17/19 until 06/19/19 at 12:46 PM, approximately 42 hours after the patient had been discharged from the ED.

The facility's laboratory department's inability to run the D-Dimer and BNP caused a delay in the availability of returned test results and increased the potential for delayed care and treatment, which could result in negative health outcomes and caused the patient to receive an incomplete MSE to rule out if an EMC existed prior to her discharge. Refer to A-2406 for additional information.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, Medical Staff Rules and Regulations review, policy review, Emergency Department (ED) Central Log review, and ED record review, the facility failed to provide within their capacity and capability an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for one patient (#6) that presented to the facility's ED seeking care out of 22 sampled patients selected from the ED Central Log from January 1, 2019 through June 20, 2019. This failed practice by the facility had the potential to affect all patients that presented to the ED seeking care and treatment of an EMC. The facility saw an average of 1,104 patient cases per month over the past six months.

Findings included:

1. Review of the facility's document titled, "Medical Staff Rules and Regulations," dated 08/2018, showed that "Emergency Services and Care" means an appropriate medical screening examination and evaluation within the capability of the facility, including ancillary services (laboratory, radiology) routinely available to the emergency department, by qualified medical personnel deemed to include emergency physicians and/or attending physicians and/or registered nurses employed by the hospital to determine whether an "emergency medical condition exists".

Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - ED to ED Transfers," dated 08/2018, showed the following directives for staff:
- The facility is to ensure the safe examination, treatment, stabilization and transfer of those patients who may require hospitalization and for varying reasons cannot be hospitalized at our facility.
- Provide an appropriate MSE to any individual who comes to the emergency department. The purpose of the MSE is to determine whether or not an emergency medical condition (EMC) exists.
- Emergency Medical Condition - is a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that absence of immediate medical attention could be reasonable expected to result in: Placing the health of the individual in serious jeopardy or serious impairment to any bodily function.

2. Review of the facility's policy titled, "Laboratory Turn Around Times," dated 05/2016, showed that:
- All STATS (without delay, immediately)/Critical (uncertain prognosis and death may be imminent) tests for basic chemistry (BMP, a test that measures chemicals in the blood and shows how well certain organs are functioning), hematology (blood and blood forming organs), coagulation (process when blood forms a clot), and urinalysis (USA, a test of urine to determine if an infection is present) testing should be reported within 25 minutes from the time received in the laboratory.
- All STATS/Critical test for CK-MB (a cardiac marker used to diagnose acute myocardial infarction, MI - heart attack), Troponin (a blood test used to help detect injury to heart muscles), TSH (Thyroid Stimulating Hormone, produces hormones that regulate the body's metabolic rate, heart/digestive function, muscle control, brain development, mood and bone maintenance), and Abuse Drug Screening (UDS, a test used to detect either illegal or prescribed substances in either blood or urine) should be reported within 50 minutes from the time received in the laboratory.
- Most routine test are reported within four hours from the time received in the laboratory (facility's on-site laboratory).
- Nursing divisions will be notified of unusual delays.

Review of Patient #6's ED record showed that:
- She (MDS) dated [DATE] at 2:21 PM per private vehicle with complaints of pain in her right calf for approximately 10 days and experienced shortness of breath for five days or more.
- Laboratory test for D-Dimer (test used to detect blood clots in the body) and BNP (test used to detect heart failure) was ordered on [DATE] at 3:53 PM and after the blood samples were collected, they had to be sent out because the facility's laboratory department was no longer able to run the test in-house.
- The patient was discharged on [DATE] at 6:53 PM.
- The results of the D-Dimer and BNP were faxed to the patient's primary care physician on 6/19/19 at 12:46 PM approximately 42 hours after she had been discharged from the ED.

During an interview on 06/20/19 at 2:29 PM Staff C, ED Physician, and Staff R, ANP, stated that they had issues with laboratory results being delayed for D-Dimer and BNP because those test were no longer ran in-house by the laboratory department, which caused delay in results being returned.

The facility's laboratory was not able to perform these test due to frequent lack of supplies as a result of non-payment to the vendor.

During an interview on 06/27/19 at 2:06 PM, Staff S, ED Physician, stated for Patient #6, he ordered the D-Dimer to rule out if the patient had a blood clot in her leg related to complaints of leg swelling and he ordered the BNP to see if the patient experienced congestive heart failure (CHF, where the heart muscle doesn't pump blood as well as it should) related to complaints of shortness of breath.

During a telephone interview on 07/09/19 at 2:15 PM, Staff R, ANP, stated that he was "on the fence" with one ED case and having BNP results readily available would have been beneficial to assist in the final determination of the disposition of the patient.

During an interview on 06/19/19 at 11:45 AM, Staff N, Laboratory Manager, stated that due to lack of payment to the vendor she received supplies from, she had not been able to produce the emergent lab tests in-house. She stated that she had to send them to an outside laboratory that caused the delay in receiving the results. She also stated that she had spoken with administration many times regarding this egregious delay in care.

During an interview on 06/27/19 at 3:00 PM, Staff OO, ED Physician, stated that he expected the BNPs and D-Dimer to be completed quickly.

During an interview on 06/27/19 at 1:00 PM, Staff C, Chief Medical officer (CMO), stated that he was unaware that the laboratory stat results were delayed over six hours.

During an interview on 06/26/19 at 2:15 PM, Staff D, Chief Executive Officer (CEO), stated that he hadn't understood the importance of the stat labs.

A hospital laboratory should have the capability to perform a D-Dimer and BNP with timely results. This facility lacked the supplies to provide the capability to perform the tests due to non payment to vendor.